Previous Topic

Next Topic

Book Contents

Book Index

Ante-Natal Consultations

  • Either from the Maternity Caresummary form, click on the tab marked Ante-Natal. Click OK after each Add screen.
  • Or right click on Maternity on the navigation form, then select Summary - select the entry you want from the selection box at the very bottom of the screen then press Skip To.
  • Or from the Maternity Management Plan, click on the AnteNatal Consultations line.

There is some difference between the data entries on the Summary and Management Plan.

Click on Skip To if you have no entry to make in a screen; this will then present the next screen.

Pregnancy Dates - This entry will be picked up from the Pregnancy Start tab.

Ante-Natal Consultation - On the Management Plan, a new column is started for each ante-natal consultation. Enter the GP the patient has seen, or a midwife if added in File Maintenance – Staff. Enter the number of weeks gestation.

Ante-Natal Symptoms - To enter these, either double click in the READ window, and select from the READ dictionary; or enter a keyword such as NAUSEA in READ Term and press Enter.

Maternal Examination:

Weight - Refer to "Weight and Height".

BP - Enter the systolic and diastolic readings. Refer to BP and Hypertension section.

Maternal Breast - The default READ term is 26.. 11 Breast examination, but other choices are 26B1 O/E - general breast exam. NAD, 26B3O/E - veins visible on breast, 26BZ O/E - general breast exam. NOS. Enter any free text notes.

Note - If 26B2 O/E -gynaecomastia is entered for a male patient, validation will exclude this entry into the female Maternal Breast Examination. Entries for male patients will show a medical history icon.

Maternal Pelvic Examination - The default READ term is 277.. 00 O/E - VE for pelvic assessment. Enter any free text notes.

Urinalysis - Glucose - The default is 466 Urine test for glucose. Choose from the result qualifier: <None>, Nil, Trace, +, ++, +++, ++++, Not examined, or Positive.

Urinalysis - Protein - Glucose and Protein – The default is 467 Urine protein test. Choose from the result qualifier: <None>, Nil, Trace, +, ++, +++, ++++, Not examined, or Positive.

Fetal Examination/Fundus - The default READ term is 271..11 O/E - fundus size - obstetric. Other options are 27... 00 Obstetric Examination and hierarchical codes, and codes from 6201 Fetal movements felt. Make an entry in Fundus. FromUnit of measure, the default is Week, but you can also choose: Stone pounds ounces, Todd unit, Units/Litre, Year, pH. In Presentation, the default is Cephalic, but you can also choose: <None>, Breech, Transverse Lie, Oblique, Unknown.

There are two check boxes: Fetal heart heard, and Fetal movementfelt.

Click on OK.